by Ashley Altadonna
For many trans and non-binary folks, hormones are an integral part of transition. While not every transgender or non-binary person may want or need hormone replacement therapy to affirm their gender identity, it’s a safe bet that those who do (and their loved ones) have questions about it. Often these questions come from misunderstandings about the way hormones work, and what they can and can’t do.
First, a quick reminder for anyone who has forgotten high school biology class…
Hormones are messenger molecules produced by glands throughout the body that deliver instructions to tissues and organs. Hormones regulate things like sleep, digestion, and emotions, as well as growth and development. Hormones affect cells in the body by binding to specific hormone receptors which tell the cell to perform certain actions.
Everyone has varying levels of estrogen and testosterone occurring naturally in their body. Hormone replacement therapy (HRT) or using “sex hormones” (typically testosterone for transmasculine folks and estrogens for transfeminine folks) can help individuals to develop secondary sex characteristics that are affirming to that person’s gender identity.
Recently, I sat down with Dr. Linda Wesp, APNP, a nursing researcher and clinician with expertise in transgender health, from Health Connections Inc., to talk about some of the most common questions and concerns folks have about HRT.
1. What will hormone replacement therapy do to me?
All hormone replacement therapies will affect changes in the body. Some changes will be permanent, while others are reversible. Some may be desirable, and others may not. Knowing how HRT will affect you can help you to make the best choices when it comes to your health, your transition, and your care.
An individual taking testosterone (frequently abbreviated to “T”) can expect to see an increase in facial and body hair, deepening of the voice, and enlargement of the clitoris to an average of 4-5 cm. These changes are permanent and will not go away if you stop taking testosterone. Trans men with a genetic predisposition for male pattern baldness may see hair loss that will likely not go away if they stop taking testosterone.
Other changes that may happen, but will probably go away if you stop taking T can include: cessation of menstruation, increased libido, increased muscle mass, redistribution of body fat from the buttocks and thighs to the stomach, increased sweat and changes in body odor, increased appetite, weight gain, coarser/thicker skin, and acne (especially in the first few years of treatment).
Individuals taking estrogen treatments can expect to see breast growth, changes in the genitals such as smaller testes, and a decrease in the amount of sperm production. These changes are permanent and will not go away if you stop taking estrogen. Other changes that may happen but are likely reversible include: decreased libido, decreased ability to get erections, increased appetite, weight gain, fluid retention, redistribution of body fat, softening of skin texture, and an overall thinning of body hair. Folks who plan on taking anti-androgen therapy by itself, without simultaneously taking estrogen, can also expect to see some of these changes, but it is unknown whether they will be permanent or reversible.
“Hormone therapy is an art and a science.” – Dr. Linda Wesp
2. Is taking hormones dangerous?
All medical treatments come with some possible risks and side effects. That’s why it’s important to partner with a medical provider who can explain the risks and benefits of HRT, and help you manage and monitor those risks. Folks taking testosterone may develop changes to their LDL cholesterol levels, which can increase the risk of heart attack or stroke. Testosterone can, in some cases, cause polycythemia, which is an increase in the number of red blood cells the body produces. This increase in red blood cells can lead to thicker blood, higher blood pressure, or blood clots. There is a possible but uncertain risk of developing osteoporosis (a thinning or weakening of the bones) if ovaries have been removed and testosterone therapy is discontinued.
People taking estrogens are also at an increased risk of higher cholesterol levels, which may increase the risk of heart attacks, strokes and blood clots. Some studies indicate that oral estrogens may increase the risk of blood clots (such as strokes or deep vein thrombosis/DVT). If you have a history of blood clots you may still be able to take estrogens, but you should talk to your doctor about transdermal or injectable estrogens.
Whether taking testosterone or estrogens, individuals may be at increased risk of developing type 2 diabetes, migraine headaches, and experiencing emotional changes. All of these risks are increased in folks who smoke, abuse alcohol, have certain pre-existing medical conditions, or are advancing in age.
“There a lot of options on how to manage someone’s HRT. If you’re feeling a certain way, typically something can be done about it. You can change the dose or the formulation. The ultimate goal of HRT is to have a good quality of life and to get on a regimen that is affirming as possible.” – Dr. Linda Wesp
3. Will taking more of a hormone increase/speed up its effects?
Many folks starting HRT are anxious to see their bodies begin to reflect their gender identity. However, taking more hormones will not hurry their effects. Too much testosterone can actually turn into estrogen. If testosterone levels are too high, an enzyme called aromatase can act as a catalyst converting the testosterone into estradiol (an estrogen). The level at which this happens is different for everyone. There are medications, called “aromatase inhibitors” that can block the process of turning testosterone into estrogen, but taking more testosterone will not speed its effects.
Estrogen, on the other hand, can’t chemically turn into testosterone. Some studies, however, have shown that certain forms of estrogen, such as estrone (typically found in oral estrogens) can block the estrogen receptors in cells so that they don’t respond to HRT as effectively. This typically happens early in treatment and is based on genetics and how someone's body responds to the pills. A blood test can be done to check someone's level of estrone. As with testosterone, taking more estrogen will not speed its effects and can possibly lead to potential health risks.
4. Will taking hormones make me/my transgender child sterile?
Human fertility is a fickle beast. Even when our hormones automatically align with our gender identity it can be difficult to know how and whether they will affect our fertility. We do know that HRT can impact the reproductive system, a fact that many younger trans and non-binary folks often aren’t even thinking about when they are anxious to start hormone therapy. Estrogen treatments can have a 50% – 80% chance of reducing sperm production permanently, even after a few months, depending on age.
Comparably, testosterone therapies typically lead to an anovulatory state and amenorrhea, which over time reduces the likelihood of conception. However, testosterone is not a form of birth control, and trans men can still ovulate and conceive while taking testosterone. The good news is that trans guys can take birth control while on T and expect to see masculinizing effects while the birth control tells the body to stop ovulation.
While many trans and non-binary folks are interested in one day becoming parents, often the financial and medical costs of collecting and storing sperm or eggs are barriers in and of themselves. Ultimately, everyone’s chances of fertility are unique and HRT may or may not impact those chances.
5. Does taking hormones increase/decrease the risk of cancer?
Long term studies seem to show that adult individuals on HRT aren't at any increased risk of cancer compared to folks who aren’t. However, there is insufficient evidence to determine exactly how much of an increased risk trans folks may experience for organ-specific cancers. The point at which someone begins HRT seems to have the greatest impact on their likelihood of developing certain cancers.
If a transgender girl started taking estrogen from age 11 or 12 they would have a similar risk of developing breast cancer as non-transgender girls, because the risk for breast cancer depends on whether breast tissue is present, and how long it has been exposed to estrogen. When we look at trans masculine folks who have been on testosterone since they were 11 or 12, there isn't typically isn't much breast tissue to check. Trans women who began estrogen later in life are probably at a lower risk for breast cancer, because the breast tissue they’ve developed hasn't been exposed to estrogen as long. Trans women who have been on HRT for several years and have breast tissue, as well as trans men who have gone through female puberty and have breast tissue need to follow the same screening recommendations as everyone else with breast tissue.
Just as with estrogen, prolonged exposure to testosterone increases the potential for certain cancers in folks assigned male at birth, such as prostate and testicular cancer. Depending on whether or not a trans woman has had an orchiectomy (surgical removal of testicles) or the amount of time she has been on estrogen, hormone treatment can eliminate or decrease the chances of prostate and testicular cancer. The prostate is not typically removed with vaginoplasty (the surgical reconstruction of a penis into a vagina), so there is still the potential for prostate cancer to develop, but folks on estrogen and specifically anti-androgen treatments are probably at less risk, because there is a direct correlation between testosterone and prostate and testicular cancer.
Testosterone may possibly increase the risk for uterine or endometrial cancers if the testosterone converts into estrogen. Testosterone can also make it more difficult to screen for cervical cancer because testosterone makes collecting the right kind of cells from a pap smear less accurate. New technologies are making it easier to screen for HPV, which is the virus that causes cervical cancer. Testosterone does not appear to increase the risk of ovarian cancer.
In some ways, the biggest contributing factor for increased risk of cancer in trans folks is the lack of access to trans competent healthcare, and trans folks being turned away from the OB/GYN for how they look.
“If the person has the body part, whether, from birth, adolescent puberty, or HRT, the part needs to be attended to.” – Dr. Linda Wesp
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